Medical School: How the “Hidden Curriculum” Snuffs Out Compassion

In the post below, “Can Empathy Be Taught?” Dr.  Chris Johnson reflects on how and why, so many medical students seem to lose that compassion for others that is “innate in all of us,” and causes many students to choose the profession in the first place. Johnson writes: “We need to prevent medical training from driving [compassion] into the background, belittling it, or even snuffing it out.”

For nearly thirty years Johnson has been practicing medicine in an area that makes great demands on both the heart and the mind—pediatric critical care. It is a field that, in the words of 19th century medical ethicist Thomas Percival requires that the physician “unite” great “tenderness with steadiness.” Johnson is a blogger and the author of  How Your Child Heals, How to Talk to Your Child’s Doctor, and Your Critically Ill Child.

Throughout most of his career, he has taught medical students, residents, and fellows. “I also served on a medical school admissions committee for some years,” he notes “and interviewed many prospective students, so I have had the opportunity to see and speak with them before the medical education system got hold of them.”

Before reading Johnson’s post, you should know what inspired it.

A few months ago, I sent him a riveting essay that I had just read in the New England Journal of Medicine, and asked if he would like to write a guest post about it.  The “Perspective,” titled “Into the Water—The Clinical Clerkships” was co-authored by a third-year medical student at Harvard, Neal Chatterjee, and Dr. Katharine Treadway, who teaches at Harvard and practices at Mass General.    Together, they describe how medical students learn to distance themselves from the sights and sounds that surround them when they move from the classroom to the hospital in their third year of training. “It is ironic that precisely when students can finally begin doing the work they believe they came to medical school to do — taking care of patients — they begin to lose empathy,” Treadway notes. “Studies have documented the high level of compassion with which students enter medical school and the sharp decline that occurs during the ensuing 4 years. . . Most of the decline occurs in the third year.”

Initially, most third-year students are overwhelmed by what they see and hear—the human condition laid bare. Patients die. Others suffer, and cry out. Some must be tied to their beds. Human flesh is “filleted,” on an operating table.

At the end of his third year, Chatterjee describes what he witnessed:

“I have seen a 24-hour-old child die. I saw that same child at 12 hours and had the audacity to tell her parents that she was beautiful and healthy. Apparently, at the sight of his child — blue, limp, quiet — her father vomited on the spot. I say `apparently' because I was at home, sleeping under my own covers, when she coded.

“I have seen entirely too many people naked. I have seen 350 pounds of flesh, dead: dried red blood streaked across nude adipose, gauze, and useless EKG paper strips.

“I have met someone for the second time and seen them anesthetized, splayed, and filleted across an OR table within 10 minutes.

“I have seen, in the corner of my vision, an anesthesiologist present his middle finger to an anesthetized patient who was `taking too long to wake up.' I have said nothing about that incident.

“I have delivered a baby. Alone. I have sawed off a man's leg and dropped it into a metal bucket. I have seen three patients die from cancer in one night.

“I have seen and never want to see again a medical code in a CT scanner. He was 7 years old. It was elective surgery.”

Inevitably, third year medical students bear witness to more human suffering than many of us see in a lifetime. “As [students] have their first experiences with patients dying, they don't know how they should respond, whether it's OK to be upset,” Treadway observes.  . . “Responses to these events are rarely discussed  . . .   most students enter medical school caring deeply, and we actually teach them not to care — not intentionally, but by neglect, by our silence.” A patient dies, and doctors leave the room, without comment.  “We place them in profoundly disturbing circumstances and then offer no support or guidance about what to do with the feelings they have in abundance,” writes Treadway.  This, she suggests, is “the hidden curriculum” (the transmission of the dominant culture) or the “professional socialization that alters the student's beliefs and value system so that a commitment to the well-being of others either withers or turns into something barely recognizable.”The impact of this hidden curriculum is profound.”

She quotes Renee Fox, a medical sociologist: “As they struggle, individually and collectively, to manage the primal feelings, the questions of meaning, and the emotional stress evoked by the human condition and uncertainty . . . medical students  . . . develop certain ways of coping. They distance themselves from their own feelings and from their patients through intellectual engrossment in the biomedical challenges of diagnosis and treatment, and through participation in highly structured, in-group forms of medical humor . . . They are rarely accompanied, guided, or instructed in these intimate matters of doctorhood by mature teachers and role models. Generally their relations with clinical faculty and attending physicians are too sporadic and remote for that.”

Ultimately, students become numb to much of what they see and hear. Or as Chaterjee puts it, “the extraordinary” begins to seem “mundane.”  He suspects that this response is an inevitable consequence of medical training, “a survival mechanism.”

Inevitably, students take their cues from those around them. Chatterjee describes the first role model he encountered when he began his third year. “ I arrived…freshly shaven, nervous, absorbent — for the first day of my surgical clerkship. As I joined my team, my resident was describing a recent patient: “He arrived with a little twinge of abdominal pain . . . and he left with a CABG, cecectomy, and two chest tubes!” This remark was apparently funny, as I surmised from the ensuing laughter. And the resident sharing the anecdote — slouched in his chair, legs crossed and coffee in hand — seemed oddly . . . comfortable.”

In the months that followed, Chaterjee learned to blend in. He sums up his experience: “The third year of medical school is like being thrown head first into water. Although the impact is jarring, eventually the experience becomes natural. We become comfortable— legs-crossed, slouched-in-a-chair, coffee-in-hand kind of comfortable.

“Occasionally, however, were moments that evoked a twinge of my old discomfort, some inchoate sense that what had just transpired mattered more deeply than I recognized at the time. These moments were often lost amidst morning vital signs, our next admission, or the differential diagnosis for chest pain.  If we focus on them closely, we see that our lives are filled with these moments. The challenge is to collect them in a meaningful way — to spend time with them, wrestle with them, allow the discomfort they generate to sit inside us.”

Chatterjee did not want to lose his humanity.  Eventually he learned to share those moments: “During my third year, I met with eight classmates for 2 hours every other week. What initially seemed an intrusion into our busy lives became an almost sacred space for recognition — both recognition that others felt similarly challenged, uncomfortable, and uncertain and recognition of moments that would otherwise have remained buried under Noon Conference attendance and potassium repletion. Most important was the shared nature of this collective self-examination, which helped buffer the inevitable discomfort and emotion that these moments generated. . .

“The shared reflection and consideration we engaged in empowered us . . . exploring some moments helped us to cherish their wonder and retain the humility they inspired, focusing on others helped us to strengthen our advocacy for patients.

“During my intern year, this reflective power has stayed with me. An experience that might otherwise seem to be an errant thread is now held carefully and closely — and eventually woven into the fabric of my training.”

After I read this essay, I looked at some of the research listed in the footnotes. In particular, I recommend “Vanquishing Virtue: The Impact of Medical Education” by Jack Coulehan. It is too long to discuss here, but I hope to write about it in another post.

Other research suggests that, at the beginning of medical school,  as students become aware that medicine is fraught with ambiguity, they begin to change. The science it turns out is not as clear-cut or “scientific” as television suggested. Or put it this way: Medicine remains an evolving body of knowledge. Bright students begin to recognize that some of what they are being taught is probably “wrong.”  In ten or fifteen years, research will topple more than a few of today’s theories and replace them with new ones.

But the real transformation comes when they begin to have contact with hospital patients. This is when idealism turns to cynicism directed against patients (particular poorer patients whose own "behaviors" have caused their illness), as well as cynicism about medicine itself—and “self-mockery”.

According to the studies about one-quarter of all med students escape this erosion of their capacity for empathy. Typically they are women who go into the "core" specialties where they see patients over a period of time—family medicine, pediatricians, ob-gyns, as opposed to proceduralists who often see a patient only for a single episode of care. (See “Is There a Hardening of the Heart During Medical School?”)

In this context, I am suspicious of a number as precise as “27 percent,” but it makes sense such hardening of the heart is not inevitable. Researchers report that some medical students are, for a variety of reasons “immunized”  against the hidden curriculum and remain extraordinarily empathetic. I would add that I know radiologists and oncologists whose imaginative and affective capacities have not atrophied. And I have met female primary care doctors who were wholly lacking in compassion.

As the “modern medicine” of the 20th century developed, doctors were counseled that they needed to detach themselves from their patients in order to defend themselves; otherwise they wouldn't survive. Today, those who study doctors suggest that the combination of hard-boiled cynicism and “medical humor” that Chatterjee’s resident exhibited itself causes burn-out.

When I sent “Into the Water” to Chris Johnson I asked him some questions: “Can compassion and empathy be taught? Can it be taught by older doctors serving as models? Does this mean that older physicians should allow their emotions to show on their faces when they are distressed by a patient's suffering?”

Below his response.

24 thoughts on “Medical School: How the “Hidden Curriculum” Snuffs Out Compassion

  1. This is a good subject. It is most splendidly displayed when a physician becomes a patient…with a very serious illness.
    The deficit is noticed very quickly; embarrassment (and even anger) rapidly sets in by direct proportion to the loss of empathy.
    Of course, highly academically adept students are most often selected for medical school. This subset is not usually over-equipped with ‘mature’ social skills.

  2. I’ll own up to it.I hated med school.My pre-conceived notions of what a doctor should be were snuffed out very quickly. I sufferred.
    I coped by turning to the arts. I tried to extract some beauty in the most horrible situations and I began to appreciate beauty in the world. Other students used alcohol or drugs or just “toughened up”. I could not.
    Do I think empathy can be taught-NO!. But med school admissions committees can and should screen for empathy among its applicants. It may just help save our former profession?
    Dr. Rick Lippin

  3. Ruth & Dr. Rick
    First,you’re absolutely right. When physicians write about becoming a patient, a great many are both embarassed and angered by the lack of empathy.
    Often, they say they didn’t really realize how much pain their patients were enduring. Or the frustrations of being in a hospital, the mis-communications among docgtor, etc. etc.
    At the same time, I’m not sure whether the major problems begin with med school admissions. (Though I think that med schools need to re-think admissions. As I have written, I think they should lower the bar (sommewhat) for grades and test scores.
    If you read Chris Johnson’s post and some of the research, it suggests that people like Chris (who is very astute at “reading” people) believe that most the students they admit are more compassionate than average before they enter med school. But then something happens to them in med school.
    My own view is that, today, the need for top grades does tend to pre-select for students who are more ambitious than tender-hearted.
    But there are a great many exceptions. When I taught undergraudates at Yale a surprising number of pre-meds took my courses in English literature.
    I taught courses in Romantic Poetry, the Victorian Novel (George Eliot was my favorite) and “modern” poets like Yeats and Wallace Stevens.
    These were difficult courses. Pre-meds risked lowering their GPA by taking them. But some students just wanted a course where they could read great literature, discuss it, write about it, etc.
    On the other hand, this was over 20 years ago. Today, many fewer undergraduates take humanities courses . . .
    I sympathize. I sometimes wish I had beocme a doctor. But I would have hated med school– the competitiveness, the sheer nastiness and the bullying. , ,
    I urge you to read “Vanquishing Virtue: The Impact of Medical Education” that I link to in the post. I think you
    greatly enjoy/appreciate it.

  4. Empathy, in some respects, has become a luxury in the crush to move patients in and out of the office. With the need to check boxes and accomplish certain tasks that are necessary to meet payment criteria, and the need to provide adequate documentation, largely to prevent litigation, little time is left for this important piece. This is what frustrates doctors who are increasingly becoming employees of larger entities. Productivity is measured not by the quality of the encounter, but only by how many RVUs you can bill.
    Indeed, medical school prepares you well to perform these tasks with little preparation or emphasis on the emotional and psychiatric aspects of disease and illness. And those best rewarded under the current system are those best at doing things to patients vs talking to them or diagnosing their illness.

  5. Keih
    I agree when you write: “Empathy, in some respects, has become a luxury in the crush to move patients in and out of the office.”
    But this is not true at all large health care organiations.
    Talk to doctors at Mayo in Rochester.
    Okay, that may be a dream example.
    But doctors at Kaiser in Northern California tell me that, these days, they are very happy with their abiity to do their job well. . .
    Doctors at Intermoutain in Utah also seem to feel able to do their jobs . .
    I agree that this is not the case in many places, but increasingly, I am hopeful that large, multi-specialty organizations (the “accountable care organiations that the reform legislation rewards) will give doctors the support they need to have the time to talk to and listen to patients.
    I also know that Medicare will be paying doctors more for this type of care as it raises payments for “Undervalued services.”
    Under reform legislation, the Secretary of HHS will have hte power to do this–without going through Congress– while also lowring payments for “over-valued services.”
    I totally understand why pepole who have been practicing medicine over the past 20 to 30 years are discouraged. But I do know some of the doctors leading health care reform fairly well, and they are truly committed to the changes that you and I believe must be made.
    Meanwhile, the law is structured in a way to greatly limit Congressional (and lobbyists’s) power to thwart changes.

  6. Is there nothing to be said for clinical detachment? Do we think that being too emotionally entangled with the patient may impact our judgement? Is it harder for a compassionate physician to give up on what might be overtreatment?
    Is there any real science behind the observations here or is this anecdotal?

  7. Joe:
    I don’t think empathy and compassion require becoming “emotionally entangled” with the patient. Likewise, I don’t think clinical detachment requires lack of compassion. I agree with you that it may seem that way to young doctors, but they can be taught otherwise by example.

  8. Fascinating discussion. Last year, I had the great privilege of being asked to be a med school reference for Sara, a wonderful young woman I know who was applying to med school. I’d been volunteering with her in our hospital’s Patient & Family Cardiac Resource Library for years. She had also spent a previous summer volunteering at a maternity clinic in Belize and two years volunteering in the E.R. of our hospital. She taught snowboarding classes in the winter, and was a skilled violinist who played in a local community orchestra that recruited mental health patients to join them – all while a full-time undergraduate student.
    In short, she was a heck of a well-rounded human being – funny, smart, caring, and an absolute joy to watch at work with the patients and families who visited our Resource Library for help.
    She had applied to four med schools, all of which contacted me directly for my recommendations.
    I was absolutely gobsmacked by how many questions about Sara’s day-to-day personality were asked in every case. Each one wanted detailed descriptions of my observations of Sara while dealing with frightened patients, their worried family members, or other hospital staff and volunteers. Did I think she was a good listener? Did I have any anecdotes of Sara’s social skills in imparting information while still staying curious and humble? Could I recall examples of Sara’s skill in dealing with a challenging workplace event?
    By the time I finished the last of the four interviews, I felt so heartened by the nature of each one.
    Med school applicants already have the brainiac marks to get accepted, but what my reference interviews revealed was an unexpected admission criterion: a focus on screening for applicants who are PEOPLE PERSONS with sound social skills who will make very good doctors someday.
    After this experience, I felt truly optimistic about the promising future of this current crop of med school students and their patients.
    I hope med school doesn’t beat the promise right out of them.

  9. Chris–
    Exactly. A blance is needed.
    This is what Jack
    Coulehani s talking about when he quotes Thomas Percival warning that during medical training one’s affective
    skills may atrophy, resulting in a state of imbalance:
    ” In the first chapter of his Medical Ethics (1803),
    Thomas Percival enjoins physicians to ‘‘unite tenderness with steadiness’’ in their care of patients. By the term
    ‘‘steadiness’’ we interpret Percival to mean the intellectual virtue of objectivity or reason, along with the moral virtues of courage and fortitude. By the term ‘‘tenderness’’ we interpret him to mean humanity, compassion, fellow feeling,
    and sympathy. Elsewhere Percival contrasts the ‘‘coldness of heart’’ that often develops in practitioners who do not cultivate such virtues with the ‘‘tender charity’’ that the moral
    practice of medicine requires. We believe that the emphasis
    on detachment in medical training promotes such ‘‘coldness of heart.’’
    (See link to Coulehan in the post. It’s a great essay.)

  10. Carolyn–
    Yes, what I read in the research about med school admissions does suggest that these days, med schools are trying very hard to admit studens who are “full human beings.”
    When I have talked at confrences, I have been very impressed by many of the younger med students who I have met there. (Third year students don’t usually have the time to attend these talks)
    But the resarch on med students also suggests that the experience of being in med school, and the “professional socialiation” that goes on there, can extinguish that capacity for caring.
    This is what med schools need to address. (Many schools realie that.)

  11. The solution to this issue as far as I am concerned is clear: Doctors need psychotherapy-type supervision. Not only supervision of medical decisions but supervision of their own inner psychological processes. I learned this from having psychotherapy supervision of my own psychotherapy cases (I am an MD specializing in psychotherapy.) Psychotherapists are unanimous about the need for supervision of their profession. But when I went for group supervision of my psychotherapy cases, it seemed obvious to me that doctors need it just as much – perhaps more because of the horrific situations they are exposed to. Without psychological supervision, they are forced to fend for themselves in the same way as soldiers are forced to do so in a war zone. This is what is happening now and well described in this excellent article.

    • Hi Brian, are you aware that psychotherapy has advanced beyond what the current psych psychotherapy delivers. It can now be used to handle all psychological and any psychosomatic illness.

      “The human body was found to be extremely capable of repairing itself when the stored memories of pain were cancelled. Further it was discovered that so long as the stored pain remained, the doctoring of what are called psychosomatic ills, could not result in anything permanent.

  12. Most everyone I went to medical school with came to the table with a well of caring and compassion. I would suggest more then your average person.
    Medical training by nature breaks each and every doctor. At some point in our career every single one of us faces something that crushes our soul. I don’t believe it can be any other way.
    At some point we all become significantly responsible for our fellow humans well being. On some days we will succeed…on some days we will fail.
    And the most human of us will dread the fact that we enteerd this profession for the best of reasons but will one day be directly or indirectly responsible for the suffering of another human being (errors…missed diagnosis….poor outcomes.)
    We cannot protect ourselves from the inevitable. If we are lucky someone will take us aside and help us heal. Soften our hearts. Teach us to survive.
    If we are unlucky we become hard…and live miserable lives.
    The trauma of training is being compounded by fears of medical malpractice and our current healthcare environment. As physicians have shifted from being the “knights” of our healthcare system to being the “knaves”.
    We have to improve training…but we also have to turn this tied of negativity away from doctors.
    Some of us feel we are being beaten up from both sides.
    I don’t have any easy solutions…

  13. I have practiced for almost 30 years. 2 years ago I was diagnosed with a lethal illness and have had to thus experience many interactions with multiple areas of the system (I have also been to the Mayo Clinic, where a relative lack of compassion, in my opinion, is partly compensated for by a superior quality of practice and system…so you can at least obtain a better picture of the reality being faced). It would take me 4 pages to describe the actual cruelty that can be embedded in lack of compassion. It really does not take much to project caring. Simple gestures mean a great deal. But the real kicker is when shoddy medicine is practiced and the doctor could care less about what you feel or think. This is not uncommon.
    I wish I could lend this illness out for a day or two. No teaching would be required after that. The entire ‘course’ will be delivered in a few hours.
    It becomes perfectly clear how litigation can be nurtured. Anger is often activated by a perceived lack of caring. Trust me, I’m a doctor.

  14. Ruth, Jordan, Brian Kaplan,
    I am very sorry about your illness.
    I’m also sorry to hear about the relative lack of compassion that you experienced at Mayo. But I am glad that you also experienced the “superior quality of care” that Mayo is known for. Given that you are a M.D. you are in a better position than most people to judge quality of care. And I agree that this could compensate for a degree of detachment . . .
    I sincerely hope you find comfort, if not cure, elsewhere.
    You’re right about anger driving malpractice suits. Attornies who defend hospitals and doctors in malpractice suits say that most often, patietns sue doctors who they never liked in the first place because they were “cold,” or “arrogant.”
    99% of patients who are injured in some way in a hospital never sue. Most people understand that doctors are human and will, inevitably, make mistakes. And most people want to trust their doctors. (The exception, I think, is when a child or baby dies. People have a very, very hard time accepting that–and may want to “blame” someone.)
    I understand what you are saying. Take a look at
    Brian’s comment– just two comments below yours.
    I think he is on to something.
    I also understand why doctors feel that, these days, they are under assault.
    Though that can lead to an “us against them” mentality which further divides doctors and patients. (The article I recommend “Vanquishing Virtue” is very good on this point. See the link in the post.)
    I wish doctors were not so afraid of malpractice suits. If you look at the statistics, you will find that in most specialties the odds that you will be sued are actually very low.
    (Ob/gyn and neurology are exceptions.)
    Some politicians have fanned doctors’ fears of being sued for their own reasons. (These politicians would like to take down the plaintiff’s bar, not so much because plaintiff’s attorneys bring malpractice suits against doctors but becuase they bring suits against corporations for selling defective products, polluting the environment etc. These “consumers’ suits” cost corporations hunderds of millions of dollars and many conservative politicians believe that this is unfair to shareholders. (Conservative politicians are more likely to identify with shareholders than with consumers.)
    If you realized that you really are not likely to be sued, you might feel less beleagured. But I understand that the fear iself is real. As Justice Brandeis said: “There are two things to fear in life: death and litigation.”
    And to be sued becuase someone believes that you hurt another human being– a patient– is terrible, especially because, inevitably, at some point or points in the course of practicing medicine, you will make a mistake, or be less than perfect.
    What you say is compelling. The comparison to soldiers in a war zone makes great sense. I wonder how many doctors reach out for help either from an individual psychiatrist, or in group therapy?
    I wonder if any med schools provide that type of help for all students, and residents?

  15. The idea of doctors having their feelings supervised is not new. Michael Balint, a doctor and psychoanalyst ran groups for doctors in the 50s and 60s. They were a bit fundamentalist Freudian for my liking but the concepts of transference and countertransference and displaced feelings are very important. It’s the ‘grit your teeth and bear it’ attitude that leads to the sort of coldness discussed here. Doctors must have space to share their feelings and empathise with each other, otherwise they default into a type of post-tramatic stress situation and practice defensive medicine.

  16. Dr. Kaplan–
    I realize that Freud is out of fashion, but the concepts you mention– transference, displacement, couter-transference remain important.
    I began my career studying and then teaching literature, and so much of Freud is in Shakespeare and other great poets. (As Freud said “The poets were here before me.”)
    What you describe as the “grit your teeth and bear it” attitude leading to coldness rings true.
    I’m also reminded of Don Berwick making the argument against solo practice and in favor of group practices where doctors can support each other: “Doctors shouldn’t be lonely.” He said this sadly– and with empathy.
    Berwick’s compassion is a large part of what gives him the ability to inspire others.

  17. I think one useful thing that can be done in the formative years of clinical training, is to become a ‘sham’ patient and be forced to crawl through a simulated obstacle course that emphasizes our (unfortunately) 37th ‘best’ medical system in the world (NEJM, Jan 2010). As an industry, it is number 1. The winners need close examination, since much of the winning is at the expense of the losers…mostly patients.
    The ‘corporatization’ of medicine would be expected to stifle compassion. Shareholder value is frequently dispassionate, by definition.

  18. Ruth–
    You are right– our medical industrial complex is #1. (Pharma in the U.S. makes more $$$ than Pharma in any other part of the developed world.
    But on having med students become “sham” patients. . . I don’t think I can agree. . . .
    Yes, young doctors should know what it feels like to be a patient. They, and their mentors should spend some time with dying patients–or patients in great pain. Just sitting with them, talking to them can be a comfort for the patient. And med students definitely need more training in how to control pain.
    If they spend time with patients in pain, they will be eager to learn what they can do to stop it.
    And I think students need to spend more time with palliative care specialists who know how to talk to patients about dying. (Many med students and residents report that they have never seen a doctor talking to a dying patient. Sadly, many doctors flee these patients who they see as their “faiures.” They just never were taught how to deal with death– or that it’s inevitable. (When a patient dies, it usually is not the doctor’s “fault.” The patient has simply come to the end of his/her life.)
    But I can’t imagine forcing students to go through much that patients suffer . . . (Long waits in waiting rooms, long waits on a gurney in a hospital hallway before getting a test—sure. But not the suffering t hat comes with even some seemingly simple tests/procedures. )
    I just don’t think that enduring pain would lead to more compassion. I am afraid it would lead to more anger among med students–and doctors.
    I would prefer to see med students learn from older doctors who say to a patient: “I realize this will hurt. I am very sorry.” If the doctor/mentor allows himself to show his sadness and concern on his face, he also is giving the patient permission to express his/her pain– to make a sound (even a loud sound), to flinch, to cry.
    If students see this, they will recognize that some of the things that they do to patients truly do hurt them.They have no choice. But the patient deserves empahty.
    And the students will realize that it’s okay to let patients know that you know, that you’re truly sorry, but (at least at this point in time) we really don’t have a better way to help you.
    This also would cause med students and young doctors to think twice about doing something that will cause pain and might not provide much, if any, benefit for the patient.

  19. Thank you Maggie for pointing me to the links, they are very interesting. I’m not sure how well accepted the BEES scoring model is, but it does seem to ring true.
    I wish they did the same study on other professions, like lawyers, to see the comparison.

  20. Excellent theme. I agree with the previous post because they have a detailed overview of the subject.
    Stwart Jenssen

  21. One can measure empathy by graph and handle any suppressed empathy with Psychotherapy [Not Psych Psychotherapy].

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